Contact Trakcing Form for Environmental Services Personn

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Overview

Front page
Landscape
portrait

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Sheet 1: Front page

	Contact Tracing Form for Environmental Workers for Ebola patients
Instructions: The following form can be used to prospectively evaluate environmental workers for potential risks while cleaning an Ebola case roon or facility. It is intended only as a template to faciliate data collection.

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Sheet 2: Landscape

EVD Healthcare Worker Activity Tracking Form

Name

Age (yrs.)

Sex

M

F

Address

City

Telephone number

County

Provider Type (Nurse, physician, laboratory, environmental services, etc.)

Site(s) Providing Care (Emerg. Dept., ICU, Lab, etc.)

Date

Notes

Date

Notes

ALL Healthcare Workers:

Nurses/Physicians/Respiratory Therapists/etc.

Worked shift on this day? (Y/N)

Helped patient to commode? (Y/N)

Entered patient's direct room? (Y/N)

Touched patient? (Y/N)

If yes, then:

Time In

Placed/repositioned rectal tube or changed bag? (Y/N)

Time Out

Changed rectal tube bag? (Y/N)

PPE worn: Gloves

#

#

#

#

#

#

#

Placed/repositioned foley catheter or changed/emptied bag? (Y/N)

Gowns

#

#

#

#

#

#

#

Intubated patient? (Y/N)

Apron

#

#

#

#

#

#

#

Placed IV or PICC line? (Y/N)

Boot covers

#

#

#

#

#

#

#

Drew blood from patient? (Y/N)

Face mask (Y/N)

Repositioned patient? (Y/N)

Face shield (Y/N)

Bathed the patient? (Y/N)

Monitored while doning PPE? (Y/N)

Stool/blood splashed on PPE? (Y/N)

Monitored while doffing PPE? (Y/N)

Cleaned up vomit? (Y/N)

Any issues with PPE? (Y/N; if yes, explain below)

Cleaned up stool? (Y/N)

Any known exposures to your skin/mucous membranes with patient's blood/body fluid? (Y/N; if yes, explain below)

Laboratory Specific:

Any know skin-skin exposure to patient (without PPE)? (Y/N; if yes, explain below)

Handled any patient samples? (Y/N)

Worker's initials

Processed any patient samples? (Y/N)

Processed any patient samples without PPE? (Y/N; if yes, explain below)

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Sheet 3: portrait

Ebola Tracking Form for Environmental Services Personnel

Page #:

Patient ID:

Employee Information Employee ID:

Name:

Sex:

M

F

Address (street, city, county, state):

Age (years):

Employee position:

Phone number(s):

Site(s) provided care (list all, e.g. ER, ICU, lab, etc.):

Date, at beginning of shift

Notes

All Healthcare Personnel

Worked shift on this day? (Y/N) If no, then STOP.

If yes, was shift overnight? (Y/N)

Provided services to a patient with Ebola or suspected Ebola? (Y/N) If no, then STOP.

Entered patient's room/same enclosed area? (Y/N)

# times entered room

Cumulative time in room (hours)

PPE worn: 2 pairs of gloves? (Y/N)

Mid-calf gown? (Y/N)

Impermeable coveralls or gown? (Y/N)

Apron? (Y/N)

Boot covers/shoe covers? (Y/N)

Surgical hood/neck cover? (Y/N)

N95 respirator & face shield? (Y/N)

PAPR & hood? (Y/N)

Supervised while donning PPE? (Y/N)

Supervised while doffing PPE? (Y/N)

# times doffed PPE during shift?

PPE soiled with stool? (Y/N)

PPE soiled with blood? (Y/N)

PPE soiled with other body fluids? (Y/N)

Any issues with PPE (e.g. exposed skin, readjustments)? (Y/N; if yes, explain in notes)

Any percutaneous exposures (i.e. needle sticks, cuts)? (Y/N; if yes, explain in notes)

Any known direct exposures to your skin/mucous membranes with patient's blood/body fluids? (Y/N; if yes, explain in notes)

Cleaned up vomit? (Y/N)

Cleaned up stool? (Y/N)

Handled laundry without obvious soiling? (Y/N)

Handled soiled laundry ? (Y/N/Unk), if yes, describe what it was soiled with in notes)

Filled or placed biohazard waste bags into clean containers? (Y/N)

Always handled/processed potentially contaminated Ebola waste with recommended PPE? (Y/N; if no, explain in notes)

Employee's initials